As part of these efforts, many providers are considering remote care services, such as e-visits, remote health monitoring, secure messaging, and regular check-in calls with patients. These remote interactions can increase patient adherence to treatment plans and lead to faster interventions when problems arise.

While payers have been slow to reimburse for remote care services (despite the clinical benefits), providers today can take advantage of Centers for Medicare and Medicaid Services reimbursement for Chronic Care Management (CCM) services to improve care management for many of their Medicare patients.

To qualify for CCM reimbursement, practitioners must spend at least 20 minutes of non-face-to-face clinical staff time per month on care coordination for CCM patients. To be included in a CCM program, patients must have two or more chronic conditions expected to last at least one year or until death, and those conditions must place patients at significant risk of death, acute exacerbation, or functional decline.

Payments for CCM services, which can be provided by physicians, physician assistants, nurse practitioners, nurse midwives and their clinical staffs, can range from approximately $43 to $141, depending on how complex a patient’s needs are, according to CMS.

When a successful remote care management model is put in place, healthcare organizations can increase annual revenues by about $500 per patient, which translates to $50,000 per year for an organization with 1,000 CCM patients.

Getting Involved

Recent data show that many providers have yet to take advantage of CCM. In fact, as of 2016, the program had touched only 684,000 Medicare patients, according to a 2017 CCM report. That’s less than 2 percent of all Medicare recipients.

One reason is that providers face many barriers when attempting to implement remote care programs. Technology, of course, is one hurdle, but CCM services also take clinical and administrative staff time and resources (such as time spent billing for CCM services and ensuring compliance).

This is why many organizations are turning to outside partners that specialize in remote care management to deliver CCM. These partners can enroll patients into the CCM program (a step that is much harder than most practices anticipate), deliver remote services each month, ensure compliance, and bill for services.

The Wright Center, a safety-net primary care provider in northeastern Pennsylvania, is one provider that sought outside help to achieve its CCM goals. The result of its partnership with a remote services provider included net new revenue within 14 days of partnering with the company, an additional $536 per enrolled patient per year, a 73 percent patient retention rate after two years, lower hospital admission rates, and higher patient satisfaction scores.

Four Key Attributes

Because many providers have found delivering remote services challenging, it’s important to select a partner that has the right model and proven success improving patient engagement and outcomes. Key capabilities to look for in a partner include:

Being staffed with nurses or other clinicians who become a trusted and integral part of the healthcare organization’s team. These clinical staff members should have a strong record of establishing productive relationships with providers in the healthcare organization and with patients remotely.

Working seamlessly with the EHR and population health tools already in place at the healthcare organization. The partnership should not result in an additional burden on IT staff members at the healthcare organization.

Providing a customized program to suit the healthcare organization’s specific needs, goals, and workflows. An organization’s CCM needs will vary depending on the patient population, in-house resources, and technology already in place. The partner should be able to tailor its services accordingly.

Proactively addressing social determinants of health and barriers to care. For example, it should be able to share results that showcase its ability to engage a senior population and address their unique needs.

As value-based reimbursement gains traction, healthcare organizations that don’t start exploring remote healthcare services will fall behind. It’s time to get involved, and CCM is a great way to start.

Drew Kearney

About the Author: Drew Kearney has been a healthcare leader since 2010, with expertise in post-ACA market opportunities and experience leading expansion initiatives in multiple markets. In 2015, he co-founded Signallamp Health, a company that offers a unique solution operationalizing population health.

As integrated care management takes hold, patients are much more likely to interact with a case manager at their healthcare provider’s office today than they were four years ago, say respondents to the 2017 Case Management Survey by the Healthcare Intelligence Network. The embedding or colocating of case managers within points of care rose from 54 percent in 2013 to 66 percent this year, the survey found.

A new infographic by HIN examines the top case manager-patient interactions, case management monthly caseloads, details on return on investment for case management programs and more case management trends.

At the point of care or behind the scenes, care coordination by healthcare case managers helps to elevate clinical, quality and financial outcomes in population health management and chronic care, the all-important hallmarks of value-based care.

2017 Healthcare Benchmarks: Case Management provides actionable information from 78 healthcare organizations on the role of case management in the healthcare continuum, from targeted populations and conditions to the advantages and challenges of embedded case management to CM hiring and evaluation standards. Assessment of case management ROI and impact on key care components are also provided.

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The increase in insured populations combined with a growing number of Medicare beneficiaries underscores the need for inpatient case management services, according to a new infographic by McBee Associates.

The infographic outlines the four key reasons why an adequately staffed case management department is important for hospitals.

Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team’s bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success and the challenges ahead.

HIN: Tell us a little about yourself and your credentials.

(Deborah Vermillion) I have been in the healthcare workforce for 36 years. I am a registered nurse. I have a master’s degree in health care administration. I am a certified senior advisor. I am also certified in diabetic education.

What was your first job out of college and how did you get into case management?

My first job out of college was in an intensive care unit (ICU)/coronary care unit (CCU) at Allegheny General Hospital in Pittsburgh as a staff nurse. After four years as a staff nurse and supervisor, I entered medical sales in the home care equipment and infusion industry. During that time it was very important to manage discharge planning as it related to the items we were providing. That was the beginning of my entry into case management.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I always knew that I wanted to be a nurse. My nursing education has led to continued growth and career development, and has been the springboard to all that I have achieved.

In brief, describe your organization.

I own a non-medical home care business. We provide activities of daily living (ADL) and instrumental activities of daily living (IADL) care to seniors in their homes. Our goal is to keep seniors at home for as long as possible. Because I am a nurse we also provide private duty nursing services. We will be expanding this product line through accreditation this year.

What are two or three important concepts or rules that you follow in case management?

Follow all cases through to completion.

Pay attention to all client details in order to avoid any unforeseen issues.

Understand that we are working in their environment, not an institutional environment. Adjust our approach to achieve the best results without being overly invasive.

What is the single most successful thing that your organization is doing now?

Because of our care for each of our clients we have been able to keep readmission rates to a minimum. When we last measured we were at five percent.

Do you see a trend or path that you have to lock onto for 2015?

We need to continue to pay attention to details. We have instituted a more robust quality management program that we hope will bring a stronger platform to our already complete care.

What is the most satisfying thing about being a case manager?

Being able to keep the client at home, aging in place up to their death.

What is the greatest challenge in case management and how are you working to overcome this challenge?

Communication between the various organizations that care for the client in the home. I constantly have to chase the Medicare agencies to ask for cross communication; most of the time they do not call back and obviously do not feel the importance in communicating to support continuity of care.

What is the single most effective workflow, process, tool or form you are using in case management today?

We have a Dementia Wise Training program that certifies our caregivers in dementia care. It is 8.5 hours of training. It has truly raised the bar of care for our clients with dementia, and it makes care much easier for caregivers as well.

Where did you grow up?

Pittsburgh, PA

What college did you attend? Is there a moment from that time that stands out?

University of Pittsburgh. Graduation day stands out. It was a very difficult five-year program and I was extremely proud and happy when I made it through.

Are you married? Do you have children?

I have been happily married for 28 years and I am the proud parent of two great sons  ages 24 and 27.
Yes and yes.

What is your favorite hobby and how did it develop in your life?

Snow skiing. I learned at the age of 22. I have improved every year and have become a relatively good intermediate skiier.

Is there a book you recently read or movie you saw that you would recommend?

American Sniper.

Do you have any additional comments about case management or the industry in general?

I believe that the case management industry needs to employ the very best. They need to be given full knowledge so that they can advise their clients of all their options as accurately as possible.

What qualities are needed for a successful case manager? A background in community nursing helps, because the case manager can better place themselves in the patient’s shoes, having worked with others from the same background, says Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care. Prior experience in home healthcare is also beneficial for case managers, as is having helped patients through major illnesses, and then transitioned them back to work or home.

I want to talk about the qualities of a successful case manager. You want to have an independent thinker because you’re going to be doing a lot on your own. You’re in a practice by yourself. It’s the way we’re set up, but of course, we call each other if we have a question.

You want self-motivation for the same reasons, because you want somebody that is going to be motivated to help the patients and be able to think outside the box.

You need a strong skill set. I’ve found that a good home health background or experience in community nursing helps the case manager determine what a patient might need, because you’ve seen that in the community.

We have several home health nurses at work for us. We have a hospice nurse that works for us and a nurse that worked with insurance claims and worker’s comp. They all have some background where they’ve helped people get through an illness and transition either back to work or get back to where they were before their illness.

Of course, you want a confident nurse, and you need somebody that has the great passion for helping people and is strong willed. You want to take care of the patients, so you’re not popular all the time with the providers. We’re really an advocate for our patients. We’re not always telling them what they want to hear.

If providers don’t have room on their schedule, sometimes we’re really begging for them to see a patient. You have to have good communication skills, be determined to take care of the patients because that is our goal as they transition back to their home or from the facilities. As you know, the personalities are strong in our field of nursing. With the providers, we are in a position sometimes to be a little forceful.

Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols presents Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care, as she shares how embedded case managers in both primary care practices and work sites are improving the quality of care and reducing healthcare costs by increasing preventive care measures at the work sites and improving care gaps for patients managed by the primary care practice.

How to best strategize the co-location of case managers at points of care? The key is to understand the population you’re serving, be very targeted, and direct your services appropriately, says Dorothy Moller, managing director in the government healthcare solutions business unit of Navigant Healthcare.

Question: New market data on embedded case management found that two-thirds of respondents have co-located case managers at points of care, including primary care practices, hospital ERs and patients’ homes. What are some payor strategies for matching case managers with providers, and how do health plans benefit from co-location?

Response: (Dorothy Moller) I must acknowledge the safety net payors, who have been co-locating case managers for a number of years  in particular in hospital ERs. Very often the case managers you co-locate are not healthcare case managers, but behavioral health or social services case managers.

In terms of strategies for co-location, it depends on the population you’re serving and what you’re trying to accomplish with that population. There are a number of places where you can co-locate case managers  not so much case managers as case or care coordination services. Very often in large multi-specialty or primary care practice settings such as federally qualified health centers (FQHCs), community clinics, or multi-specialty clinics, case managers are sometimes nurses, sometimes social workers, sometimes physician assistants performing various functions. They may link members with specific services that are non-health related or coordinate care.

The key is to understand the population you’re serving and to make sure you include case management and care coordination services appropriate for that population. If you have a very acute population with high risks or readmission or other health complications, clearly you’re going to have a different kind of co-located service and you’re going to place them in a different location than you would otherwise. If you’re trying to encourage more effective access of services, use of preventive services, use of nurse call lines, and so on, you might place those services in a primary care practice. Those are going to be very different.

Embedded case managers could even be community health workers. In fact, I’ve worked with payors in the Southwest using community health workers in that role. They are sometimes co-located within the practice but then go into the community and deliver education services there as well, sometimes in collaboration with medical and education specialists.

It depends on the population you’re serving, the types of services you want to encourage or direct members to, and the most efficient staffing model for those services. Ultimately, you must remember you’re trying to develop a better staffing pyramid within the practice so that physicians do the most complex work  where a physician’s skills and capabilities are most needed. Nurses and other staff deliver care and services appropriate for their skills, education and capabilities. Be very targeted, understand your population, and direct the services appropriately.

Dorothy Moller, MBA, is a managing director in the Government Healthcare Solutions business unit of Navigant Healthcare. She has nearly 30 years of experience specializing on a wide range of strategic issues from business intelligence and competitive analysis, to market, business and product strategy and design, business and product innovation, and business and operations turnaround and repositioning.

The majority of the survey’s 125 respondents (68 percent) have embedded programs in place to meet the expanding demand for case management services across the healthcare continuum, with the intent of improving care and quality outcomes.

Sites for embedding or co-locating of case managers ranged from primary care practices (PCP) to the hospital discharge area.

9 percent of respondents that don’t have such programs intend to implement them within the next 12 months.

The average monthly case load of an embedded case manager is 1 to 49, according to 34 percent of respondents. Slightly less than one third (32 percent) of respondents cite case loads of between 50 and 99 patients a month.

The majority of respondents (77 percent) prefer that embedded case managers be registered nurses; 55 percent prefer that they have a bachelor’s degree.

Healthcare organizations use a range of tools and practices to identify and stratify high-risk, high-cost patients and determine appropriate interventions. Most critical to the stratification process is clinical patient data, say an overwhelming 87 percent of respondents to the Healthcare Intelligence Network’s (HIN) inaugural survey on Stratifying High-Risk Patients. However, obtaining and verifying patient data remain major challenges for many respondents. Following are 10 more statistics from our survey.

Hospital readmissions is the metric most favorably impacted by risk stratification tools, according to a majority of respondents.

In addition to high utilization, clinical diagnosis is considered a key factor in stratifying high-risk patients, according to 16 percent of respondents.

Case management as a post-stratification intervention is offered by 83 percent of respondents; health coaching by 56 percent.

Diabetes is considered the prominent health condition among high-risk populations, according to 37 percent of respondents; other prominent conditions include hypertension (20 percent) and mental health/psychological issues (15 percent).

Physician referrals are cited by 76 percent of respondents as an important input for stratification, followed by case/care manager referrals (71 percent).

Home health and/or home visits are available to risk-stratified populations of 56 percent of respondents.

LACE (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.

Nearly half of respondents (45 percent) cite high utilization of the emergency department (ED) or hospital as the most critical attribute of high-risk patients.

While more than half of respondents have a program in place to identify and risk-stratify complex cases, the majority admit it is too early to tell the ROI achieved.

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement  data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

When the Sentara Medical Group evolved to a hybrid embedded case management model in 2012, case managers spent time in the practice, but also managed care through other touch points, including home visits, explains Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. How to identify high-risk patients for case management, and home visits in particular? Here, Ms. Morin addresses that question posed by The Healthcare Intelligence Network during a recent webinar.

Question: How does Sentara identify high-risk patients for case management in general and for home visits in particular? Do all patients in the case management program receive home visits?

Response: (Mary M. Morin) This program started as a pilot in 2012. It was targeted at patients that we called very important patients  high-cost, high-utilizers, the top of the pyramid. There are about 2,300 patients within 11 of our primary care sites. We kept it small, with five RN care managers. That population included all payors, most importantly our health plan patients. Because of our health plan, we were able to really study whether RN care management had an impact on the total cost of care  not unlike other organizations, if you can find a cost savings and justify the expense of having RN care managers, it makes the case much more solid moving forward with formalizing the program.

We sorted those patients by high-risk, high-cost or high-cost, high-utilizers because of chronic diseases. We looked at patient with congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), asthma, renal failure and diabetes. We excluded patients that had any traumatic event like a car accident or something that led to high-cost, or they had cancer or they were a transplant patient.

The purpose was to engage that population. It is voluntary. We studied that population for three years. It allowed us to measure our outcomes over time because we weren’t sure if there was seasonality to the patients with chronic disease: did they just not use services because of seasonal issues or because it’s a cycle issue within the chronic disease phase? After three years of data, we determined there is definitely a difference in the outcomes of this patient population and their utilization.

Home visits was one of the big differences in the model. The main reason to do home visits is not to do patient care, but to do an assessment of the patient’s environment. A lot of times, patients don’t share with us their actual living situation. They tell you that they’re walking, and then you find out they walk within a five-foot radius. The real emphasis for home visits was to get in and meet the patient in their environment.

We found that RN care managers in the home facilitated advance care planning. That is best done in the patient’s home with a family member present, not in the doctor’s office or waiting until the patient is admitted to the hospital. We found that patients appreciated the visits. The RN care managers who went in really cleaned up the medications. Patients will hold on to medications.

Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Change always incites pushback, and when Sentara Medical Group went from an embedded case management program to a hybrid approach, patient and provider pushback prevailed, recalls Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group. Among the six ways Sentara overcame resistance was to establish and maintain patient-centered relationships, by conducting comprehensive initial and ongoing assessments with patients, and developing plans of care and coaching education for both patients and their caregivers.

We maintained patient lists by populations within our electronic platforms. We came up with a standardized screen or view for all care managers. There was a lot of pushback against standardization but the key is standardizing the workflows. Should someone go out on family and medical leave, you can transfer your patient list. It all looks the same.

They were given and are still given assignments. We set expectations, which is critical. We send patient letters from the primary care physician (PCP) on behalf of your primary care provider that state we have this resource to help you should you be admitted to the hospital. We’re very focused on engaging patients. We have a brochure, and each care manager has a bio form that talks about their background.

We built workflow within the practices, within care management and within our electronic platform. We had issues: Optima, our health plan, is on a different EMR, as are the practices within our clinically integrated network. Unfortunately, the ambulatory-based care managers, the medical group care managers have to move between these two other platforms as well as our platform.

We held many meetings with home health and in-patient care coordination. Putting a face to a name is very helpful, as is lots of education and training. We had to do the electronic medical record (EMR) training. We discussed how to engage and motivate patients. What’s motivational interviewing? We have a requirement that within two years case managers are required to have their specialty certification.

We defined the care manager’s role. The main piece is to establish and maintain patient-centered relationships. They conduct comprehensive initial assessments and ongoing assessments, identify ongoing needs of the patients and possibly their caregiver, developing care plans and then providing coaching support to the patient, caregivers, and family members.

We managed resources such as transportation. We contract with the taxi service for our few patients that don’t drive but need to get to their appointments or to keep them out of the EDs in the hospitals. They manage transitions of care. They conduct advanced care planning.

Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Download this FREE report for data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.